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Percutaneous Renal Biopsy in Childhood M. W. MONCRIEFF

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Percutaneous Renal Biopsy in Childhood M. W. MONCRIEFF Postgrad Med J: first published as 10.1136/pgmj.48.561.427 on 1 July 1972. Downloaded from Postgraduate Medical Journal (July 1972) 48, 427-429. CURRENT SURVEY Percutaneous renal biopsy in childhood M. W. MONCRIEFF B.M., M.R.C.P. Derbyshire Children's Hospital, Derby, DEl 3BA Introduction depth is measured by sliding a marker down until it Percutaneous renal biopsy in adults is usually is touching the skin and measuring the distance performed by the method described by Kark & between the marker and the point of the needle after Muehrcke (1954) using the Franklin modification of removal. the Vim-Silverman needle. The method was adapted Using the White-Silverman needle (Down Bros. for use in children by Galan & Maso (1957) and and Mayer & Phelps Ltd) (Fig. 2) the depth-stop is Vernier, Brunson & Good (1957) and further modi- adjusted to allow for the skin-to-kidney depth plus fied by White (1963) who used a light aluminium 2 cm for the cutting needle (1.5 cm for an infant). A needle with a depth stop and adjustable cutting small incision is made in the skin, and the biopsy points. A recent development is the use of direct needle advanced down the same track as the explor- radiographic control (Edelman & Greifer, 1967). ing needle until the renal capsule is felt; this is penetrated with a slight jab. The needle will then copyright. Technique move with respiration. The stilette is removed and An intravenous pyelogram is performed before the the cutting needle introduced and moved down to the biopsy to confirm that the kidneys are normal in kidney which feels firm. If the outer needle is still in position and size. Haemostasis is assured by finding the perirenal fat, there is little resistance to the normal clotting and bleeding times, platelet count, cutting needle. During an expiratory pause, the prothrombin concentration and thromboplastin cutting needle is plunged into the kidney. In the next A of blood should be pause, the outer needle is pushed into the kidney generation. pint compatible http://pmj.bmj.com/ available. The procedure is explained in simple terms until the depth-stop reaches the skin, and both to the parents and the older children and a few needles removed. A second piece of tissue may be minutes spent with the younger children familiarizes obtained from higher up the kidney by angling the them with the operator. biopsy needle upwards at about 45°. It is important The operation is performed in the morning with to move the biopsy needle and take the biopsy only the child fasting. After premedication with pethidine and promazine (2 mg of each/kg up to 25 kg and 1 mg for each additional kg, with a maximum of 80 mg on September 30, 2021 by guest. Protected of each drug) the child lies prone on a firm couch with a sandbag underneath the upper abdomen. The back is cleaned and covered in sterile towels. Ligno- caine (1%) is infiltrated into the skin just below the point where the sacrospinalis crosses the twelfth rib and then straight down into the subcutaneous tissue * dorsal to the kidney. An assistant should steady the .X. .1... child at this stage, but after the local anaesthetic has .-F taken effect, the child usually lies still and may sleep. The lower pole of the kidney is located with a spinal 4j1·;·ii needle which is inserted through the area ofanaesthe- tized skin and is felt to pass through two layers of fascia and then pierce the renal capsule. When in the kidney the needle swings with respiration (Fig. 1) and FIG. 1. The exploring needle swinging with respiratory transmits arterial pulsations. The skin-to-kidney excursions of the kidney. Postgrad Med J: first published as 10.1136/pgmj.48.561.427 on 1 July 1972. Downloaded from 428 M. W. Moncrieff ·:' .l....~i.j'3..i.~=,= .~... gg ' RK-"d ''; ....··......:.: .:;': Tas~is:i'i STA I NL E.:.S .....-.- -+4-- :: = FIG. 2. White-Silverman needle. A, Outer needle with adjustable depth stop, B, stilette; C, cutting needle. FIG. 4. Specimen of kidney tissue obtained by needle biopsy. during expiratory pauses, allowing the needle to swing freely at other times. Difficulties Biopsy with a disposable needle (Travenol Ltd) (Fig. 3), which has recently been designed, is similar. Occasionally the biopsy has to be performed under When the biopsy needle is in the kidney the inner general anaesthesia if the child will not lie still. It is needle is pushed downwards to its hilt, the outer dangerous to persist with a struggling child. Difficulty needle slid inwards to the stop and the needle then may be experienced in locating the kidney and the removed. There is less sense offeeling the kidney with exploring needle should be angled slightly upwards this needle and direct radiographic control after an and then medially or laterally. A further problem is copyright. intravenous injection of urografin is useful in ensur- failure to penetrate the renal capsule, shown by the ing that the needle is in the kidney before the biopsy inner needle recoiling after insertion. In this case the specimen is obtained. outer needle should be pushed in a little further with 'The specimen, which usually consists of a pale, a small jab. Sometimes blood wells up the needle cortical; portion and a darker, medullary, portion, is when the stilette is removed, but it is worth taking a placed on a piece of card or glass slide (Fig. 4). A specimen as the needle must be in the kidney. Bleeding from the biopsy needle does not usually lead l-mm cube of cortical tissue can be removed for http://pmj.bmj.com/ electron microscopic studies, a further portion used to bleeding afterwards. for immunofluorescent studies and the remainder kept-fot light microscopy. Complications After the biopsy the child returns to the ward and These are uncommon. Macroscopic haematuria the pulse and blood pressure are recorded every 15 occurs in 16% of patients (White, 1963), but usually min for 4 hr and the pulse hourly for a further 24 hr. clears quickly with bed rest. Clot colic and perirenal The child is encouraged to drink freely so as to ensure haematoma are rarer; two of the former and three of a copious urinary output which minimizes the likeli- the latter have occurred in a personal series of 140 on September 30, 2021 by guest. Protected hood0of clot colic. If macroscopic haematuria is cases. Persistent bleeding requiring nephrectomy, or observed the child is kept in bed until this has ceased. death due to the procedure itself, are exceptionally The child can usually get up the day after the biopsy uncommon, neither occurring in 890 renal biopsies An:d4fturn home, and generally remembers little of reported by Carvajal et al. (1971). the operation. Contra-indications ·:"'··: ...ii' .::··;..i::·· i: :::· :i:·:·: :I:::::iii;:i:i:li':,.·I':·" Renal biopsy should not be performed ifachildhas :. ·:·;z:i:.isi':d'i·..·i:':··.i··" ····· ·;·;;·····::.··;· '''' only one functioning kidney, or if haemostasis is :·,··::.·: ·· ··:i:·.i·:.:: :::ii.:::l: ···:·.i:' 'L. abnormal. The presence of small kidneys and chronic :ii i':·-"· ·-:·. i:r· renal insufficiency is a relative contra-indication, as :·.· .:vl·.r the biopsy procedure is usually very difficult and histological findings are often unhelpful. Hyper- tension may be a contributory factor to subsequent FIG. 3. Disposable needle. bleeding and is also a relative contra-indication. Postgrad Med J: first published as 10.1136/pgmj.48.561.427 on 1 July 1972. Downloaded from Percutaneous renal biopsy in childhood 429 Results discussion of renal pathology and its correlation with A specimen adequate for histological purposes clinical syndromes see White, 1970). Because of these should contain at least ten glomeruli (Vernier et al., factors, renal biopsy is best performed in a few 1958). A satisfactory specimen has been obtained in centres with a special interest in paediatric nephro- 129 (92%) of 140 personally performed biopsies in logy (Black & White, 1965). children ranging in age from 6 months to 18 years. This compares favourably with an average success Acknowledgment rate of 76-5% in 2593 biopsies collected from the I would like to thank Dr R. H. R. White, for teaching me literature by Edelman & Greifer (1967), but is less the technique described, and for his advice on this paper. than the success rate of 98% achieved by White (1963) and 97-5% by Edelman & Greifer (1967). References BLACK, J.A., WHITE, R.H.R. (1965) Renal biopsy. In: Recent Application Advances in Paediatrics (Ed. by D. Gairdner), 3rd edn, p. Histological examination of tissue obtained by 307. Churchill, London. renal biopsy may aid diagnosis and guide treatment CAMERON, J.S., GLASGOW, E.F., OGG, C.S. & WHITE, R.H.R. and in of renal disease in (1970) Membranoproliferative glomerulonephritis and prognosis many types persistent hypocomplementaemia. British Medical Journal, childhood. It has been found particularly useful in 4, 7. the nephrotic syndrome when associated with haema- CARVAJAL, H.F., SRIVASTAVA, R., TRAVIS, B., DODGE, W.F. & turia and hypertension (White, Glasgow & Mills, DUPREE, E. (1971) Percutaneous renal biopsy in children. 1970); 'acute associated with a A report on 890 biopsies. Proceedings ofSecond Symposium nephritic syndrome' International de Nephrologie Pediatrique (Ed. by R. Habib persistently low level of serum Bi, globulin (Cameron and H. Mathieu), p. 166. Sandoz Editions. et al., 1970); Henoch-Schonlein nephritis if the EDELMAN, C.M. & GREIFER, I. (1967) A modified technique serum albumen is reduced (Meadow et al., 1972); for percutaneous needle biopsy of the kidney. Journal of haematuria associated with Paediatrics, 70, 81. symptomless heavy GALAN, E. & MASO, C. (1957) Needle biopsy in children with proteinuria (Glasgow, Moncrieff& White, 1970) and, nephrosis.
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